Featured Articles: Pain Management/Opioids

Complex Opioid Dependency

Friday, July 19, 2013   (0 Comments)
Posted by: Joy Ingram
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by Malcolm Butler, MD, Medical Director, Columbia Valley Community Health

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“It just doesn’t feel like I’m treating pain when the patient displays an overwhelming fixation on opioids during the encounter.”

One of the epiphanies which prompted us to re-evaluate our management of chronic non-cancer pain (which I will refer to as “chronic pain”) was a feeling that somehow we were actually making our patients worse. No amount of opioids ever seemed to be enough to redirect our patients’ attention from their pain back toward work, family, or fitness. Once on opioids, our patients didn’t want to talk about exercise, or weight loss, or stretching – all they wanted to talk about was their medications with that weird but repeated stanza of “they don’t help me at all; so could we try a little more?”

We seemed to have bred a tribe of “seekers” within the ranks of our pain patients, but they weren’t seeking insight, or recovery, or even seeking our recommendations, especially if those recommendations involved anything other than pills.  Dr. Thomas Taylor struck a deep truth when he described his pain patients as “the last of the hunter-gather tribes” whose full time work involved traveling from clinic to clinic obtaining opioids. Within themselves our opioid using patients were seeking relief from their suffering – but to all around them it was clear that their suffering was the seeker’s tool toward more opioids.

We understood that our patients were “dependent” on their opioids; the physiology of opioids taught us that. But we worried that our patients were “addicted” to opioids. There were key differences though, between the addicts we work with and our opioid using pain patients. The addicts were very straight forward about their needs: they needed another fix. We have plenty of patients who are in trouble with alcohol and dispute that they are addicted; but our hard core cirrhotics own their addiction and the loss of control they feel around alcohol. Our heroine and meth addicts often resist abstinence or treatment, but they own the fact that they are in trouble with their drug.

Our pain patients, in contrast, at the core of their beings “only use their medications when they are in pain.” How many times have you heard that refrain? In contrast to our addicted patients, our pain patients don’t knowingly seek pills -- they only seek relief.

“I hate these pills. If I wasn’t in pain I would never take another.”

“But you said that the pills don’t really help your pain.”

“They don’t, but they’re all I’ve got . . .”

And so it goes.

Complex Opioid Dependency Secondary to Chronic Pain

In March of this year David Tauben MD, Jim Walsh MD, Catherine Howe MD and I were in a discussion around this paradox of opioid using pain patients and addiction, and Dr. Tauben suggested a new term to describe this perpetual “seeking” in our pain patients: Complex Opioid Dependency secondary to Chronic Pain (COD2CP). All of our opioid using chronic pain patients become dependent on opioids, but many develop a loss of control around their medications very reminiscent of addiction. Their opioid dependency has become “complex.”

For me, this insight has been a game changer: There is pain, and there is COD2CP, and the two are separate but often comorbid diagnoses. It turns out that those of us who, with the best of intentions and with all of the appropriate guidance supporting our practice, have been prescribing opioids for chronic pain, are complicit in causing COD2CP in our patients. We leave our clinics late in the evening disheartened and emotionally tapped knowing that our pain patients are out of control, and at a loss as to what to do about it. Our patients’ suffering and behavior is getting worse, and the experts just seem to be saying “keep on prescribing.”

Here is the major insight: Most often, above 50-100mg MED, opioids are no longer treating pain, rather they are treating COD2CP.

“Complex Opioid Dependency secondary to Chronic Pain” is opioid dependency with aberrant behaviors suggesting impaired control over substance use in the setting of, and directly related to, the treatment of chronic non-malignant pain.

Diagnostic criteria:

  • Patient is using opioids in the management of chronic non-malignant pain
  • Aberrant behavior related to opioid use on at least two occasions in the past 6 months.
    • Pattern of early refill requests (>2) or dose escalation without provider direction to escalate
    • Generates multiple contacts with the prescriber’s office related to opioids
    • Pattern of prescription problems that result in a need for replacement medications (lost, stolen, spilled, etc.)
    • Supplemental undisclosed sources of prescription opioids
    • Abnormal pill counts
    • Abnormal Urine Drug Screens
  • Displays an overwhelming fixation on opioids during clinical encounters beyond the third session
  • High pain scores and repeated requests for dose escalation (no dose is enough)

As you read through that list, does it describe any of your patients? If your practice is like ours, it describes your “challenging” patients and your “frequent fliers.” It describes those patients that make the average primary care provider want to give up medicine and go into real estate. And there is the epiphany: pain doesn’t make a patient challenging, COD2CP does.

“Excellent” you say. Now I have a label for all of this behavior that has been making me nuts – now what? Just knowing that the reason the engine quit is because we are out of fuel doesn’t mean that we can land the plane!

No – but knowing that you are out of fuel allows you to pull out your “out of fuel” checklist and redirect your efforts towards a safe landing.

Below, in outline form, are our initial thoughts on how to confront COD2CP. We are beginning to deploy these recommendations in our practice and will report back on our findings in the future. All of this will be explored further during our chronic pain sessions in October at the NWRPCA fall conference in Seattle.

When a patient meets the diagnostic criteria for COD2CP:

  • If you have an integrated behavioralist model, involve them early.
  • Educate the patient as to this diagnosis and its implications:
    • Related to chronic opioid use
    • Not addiction (though shares features such as loss of control, aberrant behavior, etc)
    • Brain confounds relief of pain and suffering with continued access to opioids
  • Identify comorbid risk factors and explain to the patient how these have contributed
    • History of abuse, especially in adolescence
    • History of substance misuse, strong family history of substance abuse
    • History of psychiatric illness (PTSD, personality disorder, anxiety, depression)
  • Work to taper opioids below 50mg MED
    • Educate how chronic opioids numb and weaken the body physically, emotionally, spiritually and lead to “disengagement” (see below)
    • Educate how opioids block ascending pain pathways, but more importantly cause pain by blocking descending inhibitory pathways which are far more influential
    • Taper at 10% per month to below 50mg MED
    • If resistant, or proves unable to taper opioids, offer Suboxone consult
  • Work to move patient toward “Engagement” (credit here to Dr. Harry Rinehart)
    • Assess “Patient Engagement” with questionnaire below
    • Educate that COD2CP exacerbates disengagement and inhibits recovery
    • Educate that our most successful/functional chronic pain patients are balanced:
      • Physically
        • Regular exercise (remodels the body, builds resilience, treats depression/anxiety/insomnia, resets natural endorphin pathways)
        • Stretching, yoga, relaxation (60% of chronic pain is related to tight muscles, joints, ligaments)Healthy eating, weight loss
        • Avoidance of tobacco and other stimulant chemicals
        • Good sleep hygiene
      • Emotionally
        • Must treat anxiety and depression independent of pain
        • The social midbrain MUST be engaged
        • Family matters, must reconnect
        • Address history of abuse, PTSD, etc.
      • Spiritually
        • Confront existential angst (not where they want to be in life)
        • Make space for prayer, meditation, mindfulness
        • Volunteer – become concerned for others less fortunate and thankful for their own life.
        • Avoid the victim mentality – seek control through repeated small healthy changes
  • Differentiate between “Pain” and “Suffering”
    • Pain is the physiologic event and physiologic reaction. It is how the pain feels.
      • Typically short lived, though may be recurrent
      • May be amplified if given inappropriate salience by the CNS
      • Is reduced with opioids at MED < 50mg, and rarely improved with higher doses
    • Suffering is the behavioral response to the pain. It is how the pain looks.
      • Sensitive to secondary gain and distraction
      • Sensitive to physical, emotional, spiritual fitness
      • Improved with steadily increased opioid doses
      • Results in COD2CPTypically short lived, though may be recurrent

Patient Engagement Questionnaire

Please choose one of the three categories below that best describes your current situation:


  • Physical fitness
    • Exercise – I try to exercise one half-hour daily
    • Physical Therapy – I do my exercises as directed
    • Nutrition – I am thoughtful about what I eat, I watch my weight
    • Sleep – I am careful to do what it takes to get my sleep
    • I don’t smoke or am in a tobacco cessation program
  • Emotional fitness
    • Family – strong ties, I am a valued member of my family
    • Social – I participate with friends, with social groups, or with my religious community
    • Educated about pain – I participate in pain groups and read about fitness and health
    • Control – I can do things to control my pain; it is my pain to control
  • Spiritual fitness
    • I am thankful for this life
    • I make time for prayer, meditation, or pondering the mysteries of life
    • Volunteering – I give back; I am concerned about people less fortunate than I am
    • Suffering – I don’t like people to see my pain
    • I can locate meaning and purpose in my life and in the activities I choose to do

 Partially Engaged

I don’t feel that” Engaged” or the “Disengaged” describes my situation.


  • Physical Fitness
    • Exercise – none, sometimes I walk around the store
    • Physical Therapy – It didn’t help, so I stopped
    • Nutrition – I eat what I like and what I can afford
    • Sleep – I sleep when I can; I don’t feel restored after sleep
    • I still smoke
  • Emotional fitness
    • Family – mostly my family frustrates me and I frustrate them
    • Social – I don’t get out much anymore
    • Educated about pain – What I know about pain is that it hurts. No amount of reading about it will change that.
    • Control – I didn’t choose to have pain. It happened to me, and there is nothing I can do about that.
    • I often feel anxious or depressed
  • Spiritual fitness
    • I am angry about this life
    • I’m focused in the now; I am not a part of my community, don’t go to community or religious group activities, don’t pray, and do not worry about what I cannot see.
    • I am a victim of my circumstances, as usual
      • I didn’t sign up for this; it isn’t my fault
      • If others (my doctors) would do their job better I might actually improve
      • Nobody understands what I am going through and why I am stuck
      • I need my medicines, maybe more medicine, because nothing else helps
    • Suffering
      • I can’t help that others see my pain.
      • I can’t find any meaning or purpose in my life because of my pain


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